A lesson in serendipity

Staring at my bookshelf after a morning on service, my eyes were drawn to “The
Retrospect of Practical Medicine and Surgery,” a musty volume from 1860. Sometimes
after a hard morning of rounding, I hide in my office and distract myself by reading
a tome from the past. It gives my mind time to process the patients I have seen—the
unexplained fever, the urinary retention, the stage 4 pressure ulcers, the persistent
seizures. I pulled the book off my shelf. For years I'd been meaning to thumb through
it.

Now, I am a firm believer in serendipity. If there's a journal lying on your desk
and a gut feeling keeps you from throwing it away, it's sure to contain an article
with implications for one of your patients. On this day, I was also cogitating over
a topic for this column, and hoped there might be something inside the book for me
to write about.

A side note: The word “serendipity” was coined by Horace Walpole in
1754. It comes from “Serendip,” a former name for Sri Lanka, as referenced
in the Persian fairy tale “The Three Princes of Serendip.” Though Walpole
used the term in describing a “silly fairy tale about princes who make discoveries
by accident and sagacity,” the actual tale gives another message. These princes
were more like Sherlock Holmes, using deduction based on scant and seemingly unrelated
observations to draw a conclusion.

In the original tale, the princes see the tracks of a camel, and deduce it's lame,
blind in one eye, missing a tooth, carrying a pregnant woman and bearing honey on
one side and butter on the other. How did they know? Well, the grass was chewed on
the less plentiful side of the road, indicating blindness to the other side. Clumps
were left behind, indicating a missing tooth. The pattern of the camel tracks suggested
a dragged leg. There were ants near the tracks in a pool of melted butter, and flies
around a patch of honey. The pregnant woman was deduced by noticing a pool of human
urine, and a pattern of small hand- and footprints that indicated a woman had used
her hands to stand up after voiding.

I opened the old book. Were serendipitous words of wisdom contained in this 150-year-old
tome? I read first about fever. Dr. William Addison (no, not that Addison) started
with the assumption that fever is the expression of disorder in the corpuscles of
the blood. Since the corpuscles derive the materials of their growth from the atmosphere
and the plasma, fever must be due to disorder from these sources, he reasoned. One
type he termed hectic fever, produced by the effects of a local disease (for example,
suppuration of a lung or necrosis of a bone) on the plasma. To show that a local disease
may produce changes in the blood plasma, he described an experiment in which the rate
of agglutination of the red corpuscles seen in the capillaries of a frog's foot is
correlated to induced inflammation. This was sounding a lot like a sedimentation rate.
Maybe this was the moment of serendipity, I thought—one of my patients might
have a hectic fever.

Next I read several articles by Dr. Brown-Séquard (yes, that Brown-Séquard,
as in spinal hemiparaplegia). In the first, he discussed the cause and cures for epilepsy.
For patients who have seizures induced by touching certain areas of the skin, one
suggestion was to cauterize that area of the skin. For other epileptics, therapy suggestions
included belladonna and zinc oxide, or removing a possible alternate source: worms
in the intestine or urinary calculi. I was prepared for the next patient admitted
to me with seizures, but this didn't apply to anyone today.

Dr Brown-Séquard also wrote about sloughing bed sores in paraplegics. His
approach was preventive: using alternating hot poultices and ice to restore the circulation,
then applying galvanic current if the heat/cold treatment failed. Bedsores in paraplegics?
This was a useful topic, but I was doubtful I could get IRB approval for a galvanic
current trial.

I read on. I learned about the treatment of rheumatic fever, the diagnosis and treatment
of heart disease, uses of belladonna for incontinence, the formation of the artificial
anus (the colostomy), the treatment of lupus and scabies, the uses of the hypodermic
needle for instilling narcotics and the dangers of overdosage, the use of subcutaneous
injection, and how to remove rings from swollen fingers.

And so it seemed that my serendipitous meal wagon had come up short. The conditions
I faced on the ward today were the same as 150 years ago; the only difference was
my mental, pharmacologic, and technical toolbox. This older information was interesting,
but not mind-blowing.

But then I turned to the second section of the book. The first article I saw was “On
the Condition of the Heart in Typhus Fever,” by Dr. Joseph Bell. Dr. Joseph
Bell! This was the physician upon whom Sherlock Holmes was based. I had gone looking
for some serendipity upon which to base my column, and was led instead to the man
who embodies the original meaning of the word. It was a lesson in serendipity that
was a bit…serendipitous, after all.

Dr. Newman is a hospitalist at the Mayo Clinic in Rochester, Minn., and editorial
advisor to ACP Hospitalist.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.